Daniel Park, MD, has performed biportal endoscopic spine surgery for seven years, and part of mastering the technique boiled down to the basics.
Dr. Park, of Royal Oak-based Michigan Orthopedic Surgeons, discussed his journey with biportal endoscopic surgery and what he has learned over the years.
Note: Responses were lightly edited for clarity.
Question: How long is your tenure with biportal endoscopic surgery? What was the biggest learning curve when adopting the technique?
Dr. Daniel Park: My journey into biportal endoscopic spine surgery began in 2017. My colleague from Korea showed me his videos on biportal endoscopy, which piqued my interest. I then began practicing the technique in cadaver labs. As I transitioned to adoption in real clinical life, the biggest hurdle was figuring out the basic things. I did not know if I should use a water pump or gravity or if I used gravity, how high should the bag of fluid be. I did not know what setting to put in the radiofrequency device, I did not know if I should put epinephrine in the irrigation solution. The surgical skills needed and orientation was not that much different but the support on how to set up the case and perform the actual case was the biggest hurdle. Because there are a handful of U.S. surgeons who perform this surgery unlike when I started, talking to other surgeons and asking these questions will make one's learning curve much faster.
Q: Talk about your first biportal case and a more recent biportal case. How have your skills evolved?
DP: Compared to the first biportal case, my skills have evolved where troubleshooting fluid outflow issues, bleeding issues, knowing what types of instruments could help in certain situations, and navigating scar tissue in revision surgery has become more second nature than being anxious. I have been fortunate to have the same surgical tech in the operating room and support from certain companies that while I mastered the learning curve, they also were mastering their own learning curve. This team nature has made the cases less stressful and more efficient that we can do these case time neutral to tubular cases I used to do. As with any new technique, time has improved but the beauty of this technique is that clinical outcomes did not suffer during the learning phase.
Q: What will the next generation of endoscopic spine surgery look like? How will it be pushed forward?
DP: I believe endoscopic spine surgery won't be uniportal versus biportal. There will be certain situations where uniportal will be preferred such as in thoracic cases and certain situations where biportal shines such as cases where more bony work needs to be performed. The next generation will be the endoscopic evolution where the entire platform will progress to more ergonomic friendly instruments and higher resolution visualization. The biggest hurdle, however, will be industry support and the financial constraints. The capital cost of some endoscopic systems is too great and the disposable cost of doing the cases cuts into the margin of the case. As cases migrate into the surgery center and surgeons need to be cost conscious, the ability of endoscopic companies to deliver innovation while minimizing costs will be the lynchpin in the greater adoption of this skill set. Furthermore, I strongly feel the traditional spine companies will need to join hands with these endoscopic companies to provide more ways to provide innovation as endoscopic spine surgery expands from just laminectomy and discectomy to fusions.
Q: What advice do you have for early career and seasoned spine surgeons who want to learn biportal endoscopic spine?
DP: I believe the beauty of biportal endoscopic is the flexibility the platform has. It is not tied to one specific company and capital cost is minimal. Typical spine instruments can be married with the arthroscopy tool sets our knee and shoulder specialists have used for years. All cases that could be performed in tubular way can be adopted to biportal. I believe if any surgeon feels that biportal can help their patients recover faster, have less pain, and better clinical outcomes should slowly add this skill set by visiting surgeons, practicing on cadavers and attending society meetings. To this end, I have helped co-found the World Unilateral Biportal Endoscopy Society of America, which kicks off its first meeting in January. In my learning curve, before I widely adopted it, I would do the biportal case, then connected my two portal incisions and placed a tube to make sure I was satisfied with the completion of the goal of surgery. After three to four cases, I realized that I did everything I wanted to do and stopped "checking" my cases. Providing ways to check that one is doing no harm to the patient and making sure you are delivering the best care to the patient is paramount.